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Clerkship (CC3) > Medicine > Flashcards

Medicine Flashcards

1
Q

How do you manage the patient with DKA?

A

Admission to step-up or ICU
Frequent vitals and neuro assessment
Frequent venous blood glucose, lytes, pH, anion gap, creatinine, osmolality q2h
Assess & treat precipitating illness

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2
Q

What are the 3 pillars of DKA management?

A

IV fluids

Serum K+

Acidosis

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3
Q

What are the most common precipitating factors for DKA or HHS?

A

Inadequate insulin therapy or infection

Other factors: MI, PE, cerebrovascular accident, pancreatitis, certain meds (e.g. SGLT inhibitors), alcohol/drug use

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4
Q

What is the management of fluids in the treatment of DKA?

A

is pt in shock, severe dehydration? then NS 1L/h, otherwise 500 mL/h x4h, then 250mL/hr.
Once euvolemic, assess corrected [Na+], use 1/2NS if high/normal, add D5 to keep glucose around 14)

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5
Q

How do you manage serum K+ in the setting of DKA?

A

If K+ < 3.3 mmol/L, correct hypoK+. before giving insulin (max 40mmol/L KCL). Otherwise, run less.

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6
Q

How do you manage acidosis in the setting of DKA?

A

If K+>3.3, administer IV insulin 0.1 U/kg/h. If pH <7, give bicarb. Continue to administer insulin until anion gap closes (+dextrose if need be)

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7
Q

How do you correct Na+ for blood glucose?

A

Corrected = [Na+] + 3/10 (BG -5)

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8
Q

What are the long-term complications of diabetes?

A

Microvascular: retinopathy, nephropathy, neuropathy
Macrovascular: CAD/CVD/PVD

other: cataracts, MSK/skin changes, foot infections, sexual dysfunction etc.

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9
Q

How would you differentiate between HHS and DKA?

A

HHS - bicarb normal, BG +++++ higher than DKA, plasma Osm >320 mosm/kg. More likely to present type 2 and older and also with ALOC or confusion. Longer course of illness developing over days-weeks.

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10
Q

Is T1DM or T2DM more likely hereditary?

A

T2

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11
Q

How do you manage HHS?

A

Focus on fluids, be careful to not cause cerebral edema, don’t correct osm by more than 3 mosm/kg/hr. Use 0.1U/kg/hr insulin, use 1/2NS if corrected Na+ > 135.

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12
Q

What are the key criteria for determining that a CXR is “good”

A

non-rotated (spinous process centered between clavicles), adequate inflation (6-8 anterior ribs, 10-12 posterior ribs), exposure (vertebral body visible)

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13
Q

What are important considerations when ordering CT?

A

Watch for contraindications to contrast (renal disease, contrast allergy, able to consent).

Make sure you specify what are you looking for.

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14
Q

What is the diagnosis?

A

Left upper lobe consolidation, likely pneumonia

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15
Q

Where is the pneumonia?

A

Right lower lobe

Note that spine sign, the lungs should become darker towards the bases

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16
Q

Where is the pneumonia? What is the sign?

A

RML pneumonia (silhouette sign present). On the lateral, the consolidation is anterior

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17
Q

Where is the pneumonia?

A

Right upper lobe

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18
Q

Where is the pneumonia?

A

Left upper lobe (notice it is anterior to the fissure in the lingula

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19
Q

Where is the pneumonia?

A

Left upper lobe (again, anterior to the fissure)

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20
Q

What is the diagnosis (35yo homeless, presenting with coughing and hemoptysis)

A

Notice cavitations in the upper lungs (lucency in the lungs) - TB

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21
Q

What type of TB is this?

A

Miliary TB - hematogenous spread

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22
Q

What is the diagnosis in this person with chest pain? What is the next step?

A

Worried about aortic dissection

Most commonly CT with contrast

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23
Q

How are aortic dissections classified?

A

A -> Ascending aorta (surgical)

B -> descending aorta, distal to L subclavian

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24
Q

Preop CXR, what is the finding? What is the differential? What is the next step?

A

Infection, lung cancer, benign module?

Try to compare with previous (if >2 year likely stable)

or CT -> if suspect malignancy, then refer!

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25
Q

What is the diagnosis?

A

PE (saddle embolus)

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26
Q

What is the diagnosis?

A

Paratracheal and mediastinal hilar adenopathy - most likely sarcoidosis since bilateral, but need to rule out atypical infection and malignancy

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27
Q

55M PMHx significant for previous cardiac disease presenting with SOB

A

CHF / pulmonary edema
Notice, septal lines, Kerly B (horizontal lines going all the way out to the lung periphery), peribronchial cuffing, air bronchogram)

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28
Q

What is the finding?

A

Right paratracheal lymphadenopathy

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29
Q

What is the finding?

A

right middle lobe nodule

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30
Q

What is the finding?

A

Rib fracture (right upper lobe) notice subcutaneous emphysema

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31
Q

What is the finding?

A

Right upper lobe pneumonia

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32
Q

What is the diagnosis?

A

Left pneumothorax

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33
Q

Is alcohol a risk factor for heart failure?

A

Yes! esp if there are no other risk factors + heavy alcohol consumption

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34
Q

How is heart failure defined?

A

A clinical syndrome resulting from cardiac decompensation characterized by volume overload +/- inadequate tissue perfusion.

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35
Q

How do you classify heart failure?

A

HF with reduced ejection fraction (EF <=40)
HF with preserved ejection fraction (EF >= 50)
“borderline” if (EF 41-49)
improved (with recovered EF >40)

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36
Q

How do you differentiate between left and right-sided HF

A

left-sided -> classic SOB, orthopnea, palpitations fatigue

right sided -> tends to be lower limb edema, abdominal distension etc.

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37
Q

How do you ask about heart failure symptoms?

A

Ask about what level of exertion gets you tired rather than asking specifically about C/P or dyspnea

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38
Q

What are the signs of heart failure

A

increased JVP,
S3 gallop,
etc.

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39
Q

What is the, initial workup for suspected HF?

A

CXR, ECG, BNP, CBC, lytes, Cr, U/A, glucose, thyroid

echo

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40
Q

What causes the S3 gallop?

A

blood rushing in from the left atrium due to congestion / high atrial pressure.

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41
Q

How do you evaluate functional capacity in the patient with suspected HF?

A

NYHA classification
I - no symptoms
II - symptoms with ordinary activity
III - symptoms with less than ordinary activity
IV - symptoms at rest or with any minimal activity

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42
Q

How do you manage what are non-medical interventions in HF?

A

Lifestyle modification: stop smoking and EtOH, avoid obesity, salt & fluid restriction, exercise

Manage HTN, intravascular or valvular disease, arrhythmias, OSA, anemia

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43
Q

What medications should be avoided in the setting of HF?

A

Avoid NSAIDs, CCBs (verapamil, diltiazem), glitazones

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44
Q

What medical therapy is useful for heart failure?

A
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45
Q

What are the standard initial therapies for HFrEF?

A

ACEi/ARB or ARNI + beta blocker, MRA (e.g. spironolactone), SGLT2 inhibitor. Treat any comorbidities, may need additional diuretics to maintain euvolemia

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46
Q

What is the target dose of bisoprolol in an HF patient?

A

10 mg daily

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47
Q

What drug does NOT improve survival in HF?

A

Digoxin - reduces hospitalization, but doesn’t improve survival

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48
Q

When do you consider cardiac resynchronization therapy?

A

If they are symptomatic LVEF <30 w LBBB in sinus rhythm - put in a pacemaker into the coronary sinus.

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49
Q

When do you do ICD?

A

If patients have low EF <30% despite optimal medical therapy.

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50
Q

What are indications for cardiac transplant?

A 
Advanced (class III / IV), poor prognosis despite optimal medical and electrical device therapy.
No contraindications (e.g. infection, severe PVD or cerebrovascular disease, alcohol, drug use, VTE, fixed, high pulmonary vascular resistance, systemic multiorgan ilness)
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51
Q

What are the common causes of acute HF?

A

Medication non-adherence, ACS, infections

+++HTN -> diastolic dysfunction due to ischemia, worsened by tachycardia.

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52
Q

How do you classify acute heart failure?

A

(most common) Wet and warm (adequate perfusion, congestion -> diuretics +/- nitroglycerin)

Wet and cold (inadequate perfusion -> diuretics + inotropes)

Dry and cold (fluids)

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53
Q

How do you diagnose HFpEF?

A

Normal EF and LV volume, but with LVH, left atrial enlargement and/or other abnormalities on doppler echo

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54
Q

How do you manage HFpEF?

A

Diuretics to relieve SOB and edema, manage hypertension, treat any myocardial ischemia.

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55
Q

How do you define asthma?

A

Reversible (w/ bronchodilator) obstruction i.e. FEV1 improves by 200mL+ AND 12%
or
+ve methacholine or exercise challenge.

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56
Q

What are the important elements to ask about on history when you suspect asthma?

A 
Triggers
associated conditions e.g. eczema or nasal polyp
Smoking history
What features: cough, dyspnea
Exposures (occ hx, pets)
FH
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57
Q

What are the criteria that define good asthma control?

A

Daytime symptoms < 2 days a week, reliever < 2 doses / week
Nighttime symptoms < 1 night/week, mild
No restriction in physical activity or absence from work or school. Mild & infrequent exacerbation
PEF >90% of personal best, consistent FEV1 (<10-15% variation within the day)
Sputum eosinophils < 2-3%

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58
Q

How do we treat asthma?

A

Confirm diagnosis + provide education & a written plan
Prescribe PRN SABA or budesonide / formoterol (LABA)

Start with inhaled corticosteroid and titrate up +/- montelukast

+LABA if >12yrs

+tiotropium

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59
Q

What do you think about in difficult to control asthma?

A

Review medical adherence + lung association video for technique
Trigger avoidance
Consider allergic bronchopulmonary aspergillosis or eosinophilic granulomatous polyangiitis
Consider comorbs: PND, GERD, allergies

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60
Q

What are some asthma mimics?

A

Consider asthma mimics: COPD, bronchiectasis, vocal cord dysfunction, upper airway obstruction, cardiac disease, sarcoid, hypersensitivity or OSA

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61
Q

What is the workup for difficult to control asthma?

A

PFTs + maximal inspiratory curve
CBC, IgE, ANCA
Allergy test
CXR, CT sinuses, CT thorax

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62
Q

Identify the type of obstruction

A

A. fixed obstruction e.g. tumor

b. variable extrathoracic obstruction (normal exhalation)
c. variable intrathoracic obstruction (normal inhalation)

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63
Q

What are worrisome signs on physical exam?

A

Resp. distress, hypoxia, accessory muscle use, pulsus paradoxus, quiet chest, fatigue, decreased LOC, hyperinflation.

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64
Q

How do peak flows help with disposition?

A

If >60%, probably ok for discharge

< 25% requires admission

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65
Q

How do you define COPD?

A

Nonreversible airway obstruction (FEV1/FVC <70%)

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66
Q

What is the cause of COPD?

A

Mostly smoking or smoke exposure

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67
Q

What do you want to ask abou t

A

Smoking hx, cough, functional capacity (MRC dyspnea)
Sputum
Exacerbations - how many, admission / ICU, requiring ventilation?
Rule out comorbs: HF, anemia, deconditioning, asthma

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68
Q

What do you want to look for on physical exam

A

Look general inspection (pink puffer / blue bloater)
Clubbing - this isn’t a feature of COPD
Cyanosis
increased WOB, tripoding
Chest shape
Auscultate (wheeze, quiet, prolonged exp. phase)

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69
Q

What investigations are indicated in COPD?

A

PFTs
6-minute walk test
CXR
CT if you are r/o something else (e.g. smoking CT screen)

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70
Q

What is the non-phrarm management for COPD?

A

Smoking cessation, exercise / rehab, influenza and pneumococcal, COVID vaccine, oxygen if needed

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71
Q

What is the pharmacological management of COPD

A

Short acting bronchodilator PRN
+ long acting therapy (LAMA +/- LABA +/- ICS if frequent exacerbators)
+ oral therapy (+/- PDE-4 inhibitor, macrolide (azithromycin / erythromycin, mucolytic)
+ long-term oxygen +/- noninvasive ventilation
+ lung transplant

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72
Q

How is COPD exacerbation defined?

A

A sustained worsening of the patient’s condition beyond normal day-to-day variation acute in onset requiring a change in regular medications

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73
Q

How do you manage acute exacerbation of COPD?

A

Target O2 to 88-92%
Inhalers (ventolin + ipatropium q15 minutes)
Systemic steroids
Antibiotics if purulent

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74
Q

What are your most common pathogens that cause AECOPD?

A

H flu, Moraxella catarrhalis, Strep pneumo

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75
Q

What is the cause of dyspnea?

A

Mismatch between ventilatory drive and respiratory mechanics

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76
Q

How do you workup the patient with dyspnea?

A

Get Hx of infection, medication compliance, c/p cough
Vitals, physical exam
ECG, CXR
CBC + stufff

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77
Q

What are nonpharmacologic management of dyspnea?

A

Neurostim, chest wall vibrations, walking aids, pursed lip breathing

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78
Q

What pharmacologic management helps with dyspnea? What medications should you avoid?

A

Opioid, anxiolytic (unless they have anxiety), antidepressants

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79
Q

What is the DDx of chest pain?

A

Can’t miss: ACS, aortic dissection, tamponade, PE, PTx or esophageal rupture/impaction

Think of anatomy: MSK (costochondritis, #), Skin (Zoster), nervous (radiculopathy), GI (reflux, ulcer), cardiac (HF, valve stenosis), lung (pneumonia, diaphragmatic hernia), mediastinum (fat necrosis)

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80
Q

What is the difference in pathogenesis between stable angina and ACS?

A

ACS ruptured plaque -> +++thrombogenic material creates a thrombus, nonocclusive or occlusive (full STEMI)

in stable angina, we have progressive obstruction.

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81
Q

How do you manage stable angina?

A

Single antiplatelet therapy (aspirin) + statin

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82
Q

How do you manage unstable coronary syndrome?

A

Dual antiplatelet therapy (aspirin 160mg loading then 81 daily + (P2Y12inhibitor) ticagrelor 300 loading 75 daily or clopidogrel 180 loading + 90 BID)
Anticoagulation (heparin, DOAC (dabigatran), NOAC or warfarin)
Statin
O2 to 90%

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83
Q

What is the expected rise in Hb following 1U RBC transfusion?

A

10g/L

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84
Q

At what level of Hgb do you consider transfusion?

A

<70 or <80 if preexisting cardiovascular disease

as long as they are hemodynamically stable.

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85
Q

What are the most common transfusion reactions?

A

fever / hives, can stop the transfusion and give tylenol +/- benedryl

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86
Q

What bugs are you thinking in the febrile 17 yo M with nuchal rigidity?

A 
Acute meningitis - most concerned about bacterial causes
#1 Strep pneumo (gram +ve cocci in pairs/chains)
Neisseria meningiditis (gram negative think about shared dwellings)
H flu (gram negative)

if they are older, pregnant, EtOH or immunocompromise don’t forget about Listeria monocytogenes

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87
Q

What pattern of changes do you expect on LP for bacterial meningitis?

A

CSF showing increased protein, low glucose and ++PMNs.

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88
Q

What is empiric therapy for acute bacterial meningitis?

A

Ceftriaxone 2g IV q12h (4x usual dose for CSF)
Treat for 10-14 days if strep, listeria, 7 days if other
Vancomycin 1-2g IV q12h as adjunct to resistant Strep pneumo

+ampicillin 2g IV q4h if concerned about Listeria. (or septra if penicillin allergy)
+acyclovir if you think it’s viral

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89
Q

What is adjunctive therapy in addition to empiric antibiotics for acute bacterial meningitis? When do you give it?

A

Dexamethaosne 10mg IV q6h x4days. Give with 1st dose of Abx, do not wait for CT scan or LP

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90
Q

What is your differential in the 30yo with flank pain, dysuria and new onset hematuria?

A

Can be cystitis, pyelonephritis
STI, Vaginitis
Nephrolithiasis
Other…

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91
Q

What is the microbiology of UTI?

A

E coli in 80% of cases

KEEPS: Klebsiella, Enterococcus, Proteus, Staph saprophyticus

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92
Q

What are helpful investigations for diagnosing UTI?

A

Clinical syndrome
U/A (dipstick, micro)
Urine and blood Cx

Smell / appearance of urine not reliable for diagnosis

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93
Q

What are helpful investigations for diagnosing UTI?

A

Clinical syndrome
U/A (dipstick, micro)
Urine and blood Cx

Smell / appearance of urine not reliable for diagnosis

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94
Q

When do you not do a urine Cx

A

Don’t do urine Cx in the absence of symptoms or post-treatment.

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95
Q

When do you treat asymptomatic bacteriuria?

A

Pregnancy or invasive urological procedures.

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96
Q

What differentiates uncomplicated cystitis?

A

Young, premenopausal and nonpregnant, otherwise-healthy, women who present with classic symptoms and w/o recurrent disease.

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97
Q

What is the treatment for uncomplicated cystitis?

A

Abx 3 day of either
nitrofurantoin (100mg BID)
or
TMP-SMX

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98
Q

What is usual therapy for complicated cystitis or pyelo?

A

7-14d of TMP-SMX
7d fluoroquinolone
10-14 days of clav

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99
Q

What are inpatient options for pyelo?

A

7 days initially IV ceftriaxone, gentamicin, fluoroquinolone ( +/- amp for enterococcus) with step down PO

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100
Q

63F fever and swelling/erythema over left leg skin. What is your differential?

A 
Erysipelas
Cellulitis
Deep tissue infection
Drug eruption
DVT, venostasis, lymphedema
Malignancy or radiation rxn.
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101
Q

What is the microbiology of cellulitis?

A

Nonpurulent is Group A Strep / Strep pyogenes

Pus = Staph aureus (could be MRSA)

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102
Q

Nonpurulent cellulitis - what’s the treatment?

A

Cephalexin 500mg PO QID
Cefazolin 1-2g IV q8h
for 5-7 days.

Counsel patients that redness and swelling will persist after bacteria are dead.

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103
Q

What if you have purulent cellulitis?

A

I/D, send aspirate for C/S. May not require antibiotics.

You may add 1st gen cephalosporin for 5-7 days.

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104
Q

How do you approach the non-resolving cellulitis?

A

Potential drug/bug mismatch, could be wrong diagnosis?

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105
Q

What exposure hx do you want to ask on screening for atypical cellulitis?

A

Salt water exposure, cultured fish, shellfish/meat (butcher)/hides, bites (pets, human)

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106
Q

73M hx of diabetes non-healing ulcer on left foot for months. What is the most likely cause? What should you do on exam?

A 
Gram positives (S. aureus, strep)
Enterobacter / pseudomonas / anaerobes (less likely)
Do not do superficial swab
Look for symptoms of infection
Don't discount lack of pain.
X-ray for osteomyelitis
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107
Q

Empiric antimicrobial for diabetic foot ulcer?

A

1st gen ceph 5-7days if surface

If severe or chronic (ceftriaxone 1g IV qd + metronidazole 500 mg BID) or Pip-tazo + vanco

108
Q

55F profuse watery diarrhea, breast cancer in remission, lymphedema + recurrent cellulitis of L arm.
What should you ask on hx?

A

Characterize stool. Blood or not? Ask about associated symptoms? Prior episodes and causes if known? Travel / exposure. Meds/drugs. FH (IBD?).

109
Q

What is your workup for diarrhea?

A

Assess severity (serum electrolytes, clinical status)

Stool C+S

Stool O&P (make sure it’s in the right media, but probably not if immunocompetent)

C. diff testing.
If febrile, consider blood cultures, stool AFB or endoscopy

110
Q

How do you manage diarrhea?

A

Isolate pt (contact), provide supportive care, don’t give antimicrobials.

Stop medications if they are contributing.

111
Q

How do you treat C. diff?

A

Vancomycin PO x10-14days or give metronidazole PO

If severe + metronidazole IV

112
Q

What is the workup for pneumonia

A 
CXR +/- CT chest
CBC, creatinine
Sputum or blood cultures (if concern for resistance or ill)
Can look for Legionella Ag in urine
Sputum AFB for TB
NP swab COVID
113
Q

What is atypical vs typical pneumonia in terms of bugs?

A

S pneumo and H flu are typical (also think staph aureus, group A strep moraxella). Lobar pneumonia.

Atypical (think Legionella, Mycoplasma, Chlamydia). Appearance tends to be patchy infiltrates.

114
Q

If you have apical pneumonia, what must you consider?

A

TB

115
Q

If you have diffuse, streaky interstitial pneumonia in the patient that is immunocompromised, what do you think of?

A

Pneumocystis pneumonia

116
Q

When do you cover atypicals?

A

Definitely if they are in ICU, maybe if they are inpatient, probably not if they are outpatient.

117
Q

What is empiric therapy for pneumonia

A

Ceftriaxone +/- azithromycin
Amoxicillin-clavulanate +/- azithromycin.
if you want atypical coverage, levofloxacin or moxifloxacin

Can stop if they feel better after 5 days.

118
Q

What is the scoring system to determine if someone should be admitted for pneumonia?

A 
CURB-65
2+ should admit 3+ consider ICU
Confusion
Urea >7
RR > 30
BP >90/60
Age > 65
119
Q

How do you monitor response to antimicrobial therapy in pneumonia?

A

Improved resp. status / vitals, no need to repeat X-ray to check for improvement.

120
Q

What are the 5 causes of non-resolving infection?

A 
Drug-bug mismatch
Drug can't get to bug
Complication of infection
Wrong diagnosis
Impatient clinician
121
Q

What are the likelihood of blood transmitted infection?

A

<1 in 1 million (1 in 7,600,000)

122
Q

What are the other serious risks to remember in transfusion?

A

TACO and TRALI

123
Q

What is the difference between an antibody screen and a crossmatch?

A

Antibody screen -> plasma is screened for antibodies to test red cells.
Cross-match, we mix recipient plasma with red cells from donor.

124
Q

How do you prevent TACO?

A

transfuse one unit at a time over 3.5 hours and add lasix for patients >60 and/or with history of CHF

125
Q

What is TRALI?

A

Transfusion-associated acute lung injury
New onset or within 6 hrs of transfusion, new acute lung injury with bilateral infiltrates on CXR w/o evidence of fluid overload.

126
Q

How do you manage TRALI

A

Let lab know (need to quarantine other products)

Supportive care

127
Q

When should you order platelets?

A

Typically < 10 x 10^9/L for spontaneous bleeding
<50 for major bleeding / procedures
<100 Or neurosurgery or eye surgery

1-> why does the pt have a low platelet count? (consider contraindications to platelet transfusion e.g. TTP, heparin-induced thrombocytopenia)
2->are they bleeding? (typically mucosal bleeding)
3->do they have a procedure coming up?

128
Q

How much Plt will increase after 1 adult platelet unit?

A

15-50 x 10^9

129
Q

When do we transfuse plasma?

A

Major bleeding with INR > 1.8, massive microvascular bleed / MTP.
Remember the 1/2 life is 6-8 hrs.
Multiple clotting factor deficiencies where a product that is mores specific isn’t available.

130
Q

What is the cause of an elevated PTT in isolation?

A

Heparin, lupus, severe VwD or single factor 8,9, 11 or 12 deficiency

131
Q

What is the cause of elevated INR in isolation?

A

Liver disease, warfarin, vitamin K deficiency or single factor deficiency of factor 7

132
Q

What can cause both INR and PTT to be elevated?

A

DIC, liver disease, vitamin K+ deficiency / warfarin, high dose heparin, anticoagulation, single factor deficiency of 10, 5, 2 or 1

133
Q

What do you use to reverse warfarin emergently?

A

PCCs

134
Q

What is the diagnostic criteria for diabetes?

A

Fasting BG > 126 or 7 mM, with repeat testing
Random glucose >200 or 11.1 mM that is symptomatic

OGTT with >200 or 11.1 following 75g gluc load 2hrs and repeated on a different day

A1C> 6.5

135
Q

What are the 3 criteria of diabetic ulcer that is suspicious for osteomyelitis.

A

2cmx2cm
Probe to bone
Esr >70

136
Q

What is the course of therapy for osteomyelitis?

A

6 weeks IV

137
Q

Sputum samples, what is the best time to collect?

A

First morning sputum

138
Q

What disease should you also check if someone has a new TB diagnosis?

A

HIV

139
Q

What screening is needed for household close contacts of a new TB DIAGNOSIS?

A

Skin test

140
Q

What investigations are needed before starting treatment for TB?

A

CBC, lytes, Cr. LFTs ophthalmology for Ethambutol.
Isolate min 2 wks.
Notify public health

141
Q

What are the drugs for active tb? What side effects do you worry about?

A

Rifampine, isoniazid, pyrazinamide, ethambutol
Rifampine, warn pt about pee
Isoniazid - LFTs follow and supplement with B6
Ethambutol colour vision change

142
Q

What is the treatment for latent TB

A

Rifampin for 4 months

143
Q

What is the cutoff for induration for TB skin test?

A

5mm if special cases at high risk eg HIV, contact, ESRD, +Ve CXR, Immunosuppressed

10 for everyone else

144
Q

What tests should be performed for the initial workup of febrile neutropenia?

A

Blood cultures (draw from central + peripheral if both present). CBC, lytes, liver tests.

145
Q

What is the definition of AKI

A

26,5 mmol rise in cr over 48hr
1.5x baseline within 7 days
Urine volume <0.5mL/Kg/hr x 6hr

146
Q

Ddx for pre-renal AKI

A

Hypovolemia
Third spacing or bleed
Drugs: ACE/ARB, NSAIDs (AIN), contrast agents (ATN), Lasix, thiazides, Septra, aminoglycosides, amphotericin B.
Renal artery stenosis including hypercalcemia

147
Q

What renal meds cause issues

A

Lithium, tenofovir

148
Q

Post renal ddx

A

Obstruction risk factors urinary symptoms, recurrent uti, renal colic, prostate issues, long-standing DM, etc.

149
Q

Intrinsic renal disease what are the causes

A

Glomerular (nephrotic vs nephritic), tubular (drugs), vascular (thrombotic microangiopathic disease TTP / HUS, vasculitides, lupus, polyarteritis nodosa) , interstitial (idiopathic vs secondary (MM, lupus, sarcoidosis) vs meds)

150
Q

What are some classic syndromes of interstitial disease

A

2month Hx if fatigue or B symptoms from previously healthy, hématurie and protéinuria and worsening kidney function.

151
Q

If you get staph aureus back, is it ever a contaminant?

A

No. You must treat it.

152
Q

What are the risk factors for staph aureus bacteremia?

A

IVDU, Central lines, Prosthetics, Surgery, Diabetes, Immune suppression.

153
Q

When do you need to repeat blood cultures for staph aureus?

A

2-4 hrs post.

154
Q

What are the signs of complicated staph aureus

A

Endocarditis, positive f/u blood culture post abx, osteomyelinitis, metastastic infection

155
Q

What is the workup for staph aureus bacteremia

A

Repeat blood cx
Echo , TEE if intracardiac,
ID consult, source control
Abx, empiric with vanco or dual therapy if septic shock or IE
Definitive is cefazolin 2g IV q8h, cloxacillin 2g IV q4h
Vanco if MRSA, if hardware then rifampin, aminoglycosides

156
Q

What is the danger of hypernatremia?

A

Acutely, this causes brain cell shrinkage; chronically the brain adapts by increasing its intracellular osmolarity; overly rapid correction can lead to demyelination and/or cerebral edema.

157
Q

What is a safe rate of correction for hypernatremia?

A

6-8 mmol/L/day

158
Q

What is “free water”

A

The volume of solution that can be removed, leaving behind an isotonic solution

159
Q

How do you approach polyuria?

A

Either - you are losing sodium and have concentrated urine OR you have water diuresis (dilute urine)

160
Q

What are the causes of solute diuresis? (high Urine osm, but LOW Na)

A

Glucose (DM), Urea (often due to excessive NG/G tube feeding), NaCl (loop diuretic, salt-wasting nephropathy)

161
Q

How do you distinguish between central and nephrogenic DI?

A

Give patient ddAVP and see if they concentrate the urine. If they do, then it’s central DI, if they don’t then it is nephrogenic DI (bc they are resistant)

162
Q

How do you manage hypernatremia?

A

Give free water: PO or IV; D5W, 2/3 & 1/3, 1/2 NS. Goal is 1.5 cc/kg/hr of free water. BUT keep in mind they may also have a sodium deficit. That’s why 1/2NS is good. Monitor, treat underlying cause & replace additional losses.

163
Q

What is the danger of hyponatremia?

A

Acutely - cerebral edema; the danger is that we do not want to correct too quickly because that can cause the cells to shrink and demyelinate

164
Q

How do you correct plasma Na+ for glucose?

A

add 4 for each 10mmol of glucose rise

165
Q

How do you know if hyponatremia is truly a problem?

A

Check the serum osm! if it is not low, then you have something else suppressing the Na+

166
Q

How do you approach the diagnosis of hyponatremia?

A

Excessive intake (e.g. psychogenic polydipsia)
OR
Why is there ADH when there shouldn’t be?
Either:
1) SIADH (ectopic, CNS/lung disease, drugs (SSRIs, MDMA), hormone deficiency (cortisol/T4), stress)
2) True hypovolemia (hemorrhage, GI losses, diuresis, skin loss, third-spacing)
3) Hypervolemia but with arterial volume depletion (HF, cirrhosis)

167
Q

How do you manage hyponatremia with seizure?

A

Attend to ABCs, give IV benzos, 3% NS (150mL bolus) and continue to 5mmol increase)

168
Q

How do you manage chronic hyponatremia?

A

Moderate symptoms (confusion, nausea, vomiting)
Acute hyponatremia -> 3% NaCl
Otherwise, treat the cause

Is Na<120 and or at risk of dilute polyuria -> give DDAVP

169
Q

What are the contraindications to LP?

A

Bleeding problems - uncorrected coagulopathy, low platelet (<40), antithrombotic therapy (DOAC, heparin, LMWH, Clopidogrel / Ticagrelor)
Risk of brain herniation (increased ICP),

170
Q

Where do you send the fluid?

A

4 Cs
Chemistry
Cells: micro / cytology
Crystals

171
Q

How do you differentiate between bacterial and viral meningitis?

A

WBCs +++ PMNs (>10^9) = bacterial
LOW glucose = bacterial
HIGH protein = bacterial (>1g/L) there’s schmuck

172
Q

How do you distinguish transudative vs exudative ascites ?

A

SAAG = serum - ascites albumin
If >11 = transudate (likely cirrhosis, CHF)
If <11 = exudate (cancer, inflammation, TB -> capillary damage).

173
Q

When d you suspect SBP?

A

if paracentesis is transudative ascites AND PMNs > 250 x10^6

174
Q

What are light’s criteria for pleural infusion?

A

LDH pleural fluid : serum < 0.6
AND
Total protein pleural fluid : serum < 0.5
AND
LDH pleural fluid < 2/3 upper limit of normal for serum

175
Q

What produces an exudative pleural effusion? Transudate?

A

Exudate: Cancer, infection, PE

Transudate = CHF

176
Q

What are the causes of an unconjugated hyperbilirubinemia

A

Non liver: lysis of red cells (hemolytic anemia or drugs e.g. sulfa, nitrofurantoin, ribavirin) or bleeding into a cavity -> hematoma
Liver: decreased uptake (rifampin or CHF), decreased conjugation (gilbert, Crigler-Najjar, Estrogen)

177
Q

What are the causes of decreased excretion of bilirubin conjugates?

A

Decreased excretion of conjugates (Dubin-Johnson, Rotor, Hereditary Cholestasis)

178
Q

What are the causes of hepatocellular damage leading to conjugated hyperbilirubinemia?

A

Hepatocellular damage (Viral hepatitis, alcoholic liver disease, drugs (acetaminophen, INH, stasis), sepsis

179
Q

What can cause intrahepatic cholestasis?

A

Intrahepatic cholestasis: infections (cancer, infections, sarcoid, TB / granulomatous disease), drugs (OCP amox/clav)

180
Q

What can cause biliary obstruction?

A

Obstruction: Gallstones, bile duct carcinoma, sclerosing cholangitis, pancreatitis, extrahepatic tumors.

181
Q

What is the classification of acute liver failure?

A

Fulminant (<8wks previously healthy), Subfulminant (<26wks previously healthy)

182
Q

What are the clinical parameters of acute liver failure?

A

Confusion, jaundice, GI bleed, ascites

183
Q

What are the biochemical signs of acute liver failure?

A

Increased INR, Bili Cr

Decreased Albumin Glu

184
Q

What 5 conditions that cause an ALT/AST >1000

A

infection: viral hepatitis (A / B acute)
autoimmune: autoimmune hepatitis (classically in pregnancy)
vascular: Budd-Chiari - thrombosis of the hepatic vein. Diagnosed with doppler U/S
drugs/toxins: acetaminophen -> give N-acetyl cysteine
acute biliary obstruction: often gallstone

185
Q

What is the relevant ROS of Jaundice?

A

B symptoms (cancer)
Joint pain/ Swelling (autoimmune)
Wilson disease (psych symptoms, kayser fleischer ring, hemolytic anemia)
Hemochromatosis (bronze skin + diabetes)
Alpha-1-antitrypsin deficiency (lung problems)
Sicca syndrome: Itchy dry eyes or mouth (PSC / PBC)
Missed menses (cirrhosis)

186
Q

How is the hepatocellular pattern different than cholestasis biochemically?

A

Hepatocellular: AST/ALT > 500 u/L, ALP < 3x Upper Limit of Normal
Cholestasis: ALP+++ >3x limit of normal

187
Q

What causes ALT 200-500?

A 
Alcoholic liver disease
NASH
Viral hepatitis (chronic)
Wilson disease
Hemochromatosis
188
Q

Why doesn’t AST / ALT increase as much in an acute on chronic insult to the liver? What is the W of cirrhosis?

A 
Bc there's just less liver cells to break down.
Initially - things are normal
1) Low platelets
2) INR goes up
3) Albumin goes down (ascites)
4) Bilirubin goes up (encephalopathy)
189
Q

What are the complications of liver cirrhosis?

A 
Ascites -> Hepatic hydrothorax
SBP
Hepatorenal syndrome & Hepatopulmonary syndrome
Variceal hemorrhage
Loss of synthetic function
Portal HTN
Hepatic encephalopathy
HCC
etc.
190
Q

How does ascites predict survival?

A

2 year survival is 50%.

191
Q

How do you prognosticate liver disease with the child-pugh classification?

A 
A = 5-6, 100% 1 yr survival
B = 7-9, 80% 1 year survival
C = 10-15 45% 1 year survival
192
Q

How do you manage cirrhosis?

A 
Treat underlying cause
Vaccinate HAV/HBV
Abstain from alcohol
Screening endoscopy (if plt < 100)
U/S for liver cancer
193
Q

How does UGIB present?

A

hematemesis or coffee ground emesis
Melena
Hematochezia (with brisk UGIB or local LGIB)
Iron deficiency anemia

194
Q

How do you differentiate melena from constipation?

A

Melena will turn the toilet paper black (not green or brown)

195
Q

What are the most important features of the physical exam for the acute GIB?

A

Vitals + postural vitals; ABCs
Look for icterus, pallor, lympadenopathy, tealgiectasia
Abdo -> ascites, distended abdo wall veins, masses
DRE

196
Q

What do you do if you have an acute UGIB and you’re worried about variceal bleed?

A 
Stabilize, Cross/type
NS bolus
Monitor U/O with foley
Correct coagulopathy
Call ICU
Call gastroenterology
IV pantoprazole infusion (80mg bolus, 8mg/hr)
IV octreotide
IV ceftriaxone
Albumin -> helps it stay intravascular
Intubation if needed to protect airway
197
Q

What are the labs for acute GIB?

A 
CBC pre/post
BUN
Cr
INR
LFTs
198
Q

What red flag symptoms do you worry about in the outpatient setting?

A 
New onset symptoms with age > 50
FH
New onset abdo pain
Nocturnal diarrhea
Rectal bleeding, melena
Unexplained iron deficiency
Abdo mass
B symptoms
199
Q

How do you send tests for celiac disease testing?

A

IgA + IgG level (otherwise if low false negative)

tTG

200
Q

How do you work up a PUD that is hemodynamically significant?

A

Stabilize, ABCs, urgent scope

201
Q

What are the causes of PUD?

A

NSAIDs or H pylori.

202
Q

What methods can be used to test for h pylori?

A

Serology (if they’ve never been exposed, doesn’t tell you if active)
Biopsy
Urea breath test.

203
Q

What is the therapy for H pylori?

A

Quadruple therapy: PPI, tetracycline, metronidazole, bismuth.

204
Q

What are the complications of H pylori infection.

A

Gastritis, gastric atrophy, ulcer, MALT lympoma, gastric cancer

205
Q

What is the Ddx for LGIB?

A

BRBPR acute: diverticular bleed, ischemia (pain then blood), angiodysplasia, inflammation, hemorrhoid
Anemia +/- BRBPR, melena ->tumor!!

206
Q

What are the screening tests for colon cancer?

A

FIT test (fetal immunohistochemistry test) detects blood in stool q2y between 50-74 if no colonoscopy in last 10 yrs
Unless if family history of colon cancer / polyps (or personal history) in which case it goes to…
Flex sig or colonoscopy.
if FIT +ve must have colonoscopy

207
Q

What HIV test should you order if you are worried that someone has HIV?

A

HIV test = HIV 1&2 antibody + P24 antigen
Rapid HIV POCT = HIV-1 and HIV-2 antibody (but can be negative if in window last 3 months)
Neonate = HIV DNA PCR (bc they may get antibodies from mom)

208
Q

When after exposure do HIV+ve individuals present with “seroconversion syndrome”?

A

6 weeks.

209
Q

What do you counsel patients on prevention of transmission?

A 
Undetectable virus = untransmissible
HIV prophylaxis
Disclosure - mandatory with all partners
Condom use
Risk of transmission with pregnancy (w/o treatment 25%, w 1%), blood donation, needle stick (67/10000)
210
Q

What do you need to do if someone has a new diagnosis of HIV?

A

Tests: coinfections (e.g. gonorrhea, chlamydia, syphilis, TB, Hepatitis (A,B,C), HPV (annual pap)
Baseline blood work: CBC, Electrolytes, Cr, LFT, Lipids, glucose, urinalysis, beta-hCG
Stage: Confirm diagnosis, viral load, CD4+ count
Testing for drug compatibility: HLA-B570 testing, Tropism (CCR5), G6PD assay
Vaccinations: Annual flu vaccine, prevnar, then pneumovax, Hep A and B, HPV.

211
Q

What are the 4 stages of the HIV life cycle that are targeted by ARVs?

A
  1. Virus Entry
  2. Reverse transcription
  3. Integration (into genome)
  4. Budding & maturation.
212
Q

What are some examples of entry inhibitors for HIV

A 
CCR5 antagonists (maraviroc, used for drug resistant HIV)
Enfuvirtide
213
Q

What are some examples of NRTIs (backbone x2) for HIV?

A

Tenofovir (renal, bone side effects), Abacavir (HLA-B5701), Lamivudine, Emtricitabine

214
Q

What are NNRTIs for HIV?

A

Efavirenz (psychiatric side effects) etc.

215
Q

Integrase inhibitors for HIV?

A

_ravir
RALtegravir, dolutegravir, elvitegravir, bictegravir
causes dyslipidemia

216
Q

Protease inhibitors (old drugs) for HIV?

A

_navir

Need boost + ritonavir, dyslipidemia, cardiovascular disease, drug/drug interactions

217
Q

How is virologic failure for HIV defined? What causes it?

A

Failure to get under 50 copies /mL on 16-24
Non-adherence, viral resistance, change to drug metabolism.
Better to take a drug holiday or not start rather than promote resistance.

218
Q

At what threshold do you start worrying about opportunistic infections?

A 
<200 = PJP, fungi, cryptococcus
<100 = Toxoplasma
<50 = MAC, CMV
219
Q

What is primary prophylaxis for PJP & toxoplasma in HIV?

A

Septra (160/800) or Dapsone 100mg / 200mg (if toxoplasma)

220
Q

What is prophylaxis for MAC with HIV?

A

Azithromycin 1200mg/day

221
Q

What do you expect in inflammatory vs septic synovial fluid?

A

Viscosity low -> more likely inflammatory, elevated cells but < 7500
High 50000+ cell count with >75% PMN tends to be septic (and obvs if gram stain / Cx comes back)

222
Q

What is the approach to monoarthritis Ddx?

A

R/o trauma
Septic until proven otherwise
Crystal arthritis
Hemearthrosis

Less commonly (sickle cell bony crisis, reactive arthritis, lyme, mono-articular flare or osteoarthritis).

223
Q

What types of illnesses can cause pulmonary-renal syndromes?

A

Infections (most common: stepsis, streptococcal toxic shock, HIV+/- opportunitistic)
Drug/toxin
Autoimmune (Small or medium vessel, SLE)
Autoinflammatory (sarcoidosis, IgG4)

224
Q

How do you classify vasculitis?

A

Large vessel: temporal arteritis, takayasu’s (pulseless disease)

Medium vessel: polyarteritis nodosa, kawasaki (paed’s)

Small vessel: ANCA+ve (GPA, eGPA or microscopic polyangiitis (pANCA)), non-ANCA (IgA aka HSP etc.)

225
Q

When should you think about vasculitis?

A

Pulmonary-renal syndrome (small vessel)
Headache + vision changes esp if older (giant cell arteritis)
Fever + purpura / multisystem involvement w/o infectious cause.

226
Q

What do you need to do if you suspect GCA?

A

Initial work up to r/o ACS, stroke or intracranial bleed (CT head),
1mg/kg prednisone IV.
In visual loss -> ophtho consult, pulse 1g solumedrol IV for a couple days, then drop to 1mg/kg.
Temporal artery biopsy, image the aorta (echo, MR angiogram etc.)

227
Q

What are the side effects / risks that we need to watch out for when starting high-dose steroids?

A

Hyperglycemia, acute mental status change (take early in the day), HTN, immunosuppression (very high doses may require PJP prophylaxis), avascular necrosis of the hip, bleeding ulcers (PPI prophylaxis)

228
Q

MCA lesion what is the presetnation?

A

Contralateral hemiparesis (face/arm > leg)
Contralateral hemisensory impairment
contralateral homonymous hemianopia or quadrantinopia
Eyes deviate towards the side of the stroke (away from the hemiparesis)

229
Q

What features are specific to right MCA stroke

A

Neglect - anosognosia / asomatognosia or impaired awareness of left

230
Q

What is the key distinguishing feature of left MCA stroke

A

aphasia

231
Q

What is the difference between FLAIR and DWI

A

FLAIR shows old strokes and new as white, DWI shows last 7-10 days as white

232
Q

What is the characteristic symptoms of an ACA infarct

A

Contralateral weakness of leg&raquo_space; arm

Contralateral hemisensory impairment in same distribution

233
Q

What is the presentation of PCA stroke?

A

Contralateral homonymous hemianopia or quadrantinopia
Contralateral sensory impairment
Acute amnestic syndrome (temporal)
Thalamic aphasia (left thalamus)

234
Q

How does a basilar artery stroke present?

A 
Trouble speaking swallowing
Double vision, gaze palsy
Vertigo
Contralateral weakness or bilateral weakness
Crossed sensory or motor signs
CN palsy
Ipsilateral or bilateral incoordination
Ataxia
Altered LOC.
235
Q

How does a PICA stroke (lateral medullary syndrome) present?

A

Ipsilateral - facial sensory loss pain/temp, limb ataxia, gait ataxia, nystagmus, N/V, vertigo, hoarseness, dysphagia, Horner’s
Contralateral - hemisensory loss of arm/leg/trunk to pain/temp
Scanning dysarthria

236
Q

when do you give tPA? When do you EVT?

A

<4.5 hours since onset of symptoms or last well.
+/- thrombectomy if large branch occlusion.
Endovascular thrombectomy between 4.5-24 hrs post symptom.

237
Q

What is the absolute contraindication to tPA

A

Bleeding, ICH, elevated BP (185/110+), INR>1.7 / DOAC wiithin 48 hrs, aPTT increased, low platelet <100,000.

238
Q

What are stroke mimics?

A

Seizure, migraine, presyncope, psychogenic

239
Q

What is the definition of TIA?

A

Brief neurological dysfunction <1hr, full recovery no evidence on imaging of stroke.

240
Q

What do you want to do when someone presents with TIA?

A

Determine cause (MRI ASAP, CT if you can’t, CTA and or MRA)
Bloodwork (fasting glucose, lipids, A1C, CBC, Lytes, LFTs, Cr, B12 TSH, hypercoags if FH or prev hx clot)
Address risk factors (HTN, hyperlipidemia, DM, smoking)
Treat extracranial carotid artery disease,
Cardiac exams (ECG, echo, 48hr holter)

241
Q

When should TIA patients get referred for endarterectomy?

A

> 50% stenosis, esp if 70-99% stenosed.

100% occlusion is not treated with surgery

242
Q

What is the most common cause of intracellular hemorrhage?

A

If deep, likely HTN, otherwise amyloid or vascular abnormality

Others: coagulopathy, tumor, CVST

243
Q

What other imaging should you get 2-3 months post-brain bleed?

A

MRI with gadolinium contrast.

244
Q

What chemo agents can give hematuria

A

cyclophosphamide / ifosphamide

245
Q

What is the risk factors for neutropenia that warrant staying in hospital?

A

ANC < 500 / ul
Immune suppression
Foreign bodies (eg. central lines)

246
Q

What is the 1st line therapy for most mass effect oncologic emergencies?

A

Dex 10mg push then 8mg BID.

247
Q

In what patient population should you avoid doing rectal exams

A

Febrile neutropenia - want to avoid perirectal abscess

248
Q

What are some triggers for DIC?

A

Sepsis, motor vehicle accident, acute stressors,

249
Q

What lab signs would you see for DIC?

A

CBC blood film (schistocytes)
Plt (down)
INR, PTT (up)
Fibrinogen (down)

250
Q

What is the clinical picture for TTP?

A 
FATRN
Fever
Anemia (hemolytic)
Thrombocytopenia
Renal disorder
Neurological disorder
251
Q

What is the differentiation between TTP and DIC on lab?

A

TTP does not deplete clotting factors so fibrinogen INR and PTT are normal

252
Q

How do you treat DIC?

A

Supportive care, fibrinogen, cryoprecipitate, FFP, plt

253
Q

How do you treat TTP?

A

Plasma exchange (call hematology)

254
Q

How is ITP differentiated from DIC and TTP

A

Everything is normal except low platelets. Diagnosis or exclusion;

255
Q

ITP treatment?

A

Prednisone, IVIG, rituximab, splenectomy.

256
Q

How is HIT different from other thrombocytopenia?

A

Typical onset about a week after starting heparin. PLTs are 100ish, thrombosis

257
Q

What is the 4T score for HIT?

A

Time
Thrombosis
Thrombocytopenia nadir
AlTernative diagnosis

258
Q

What are the causes of macrocyclic anemia?

A

B12, thyroid, folate (very rare), pernicious, cirrhosis, alcohol, drugs (MTx, 5-FU)

259
Q

What can cause a normocytic anemia? With high retics

A

High retics: bleed,
intrinsic: sickle cell, hereditary spherocytosis, G6PD, PNH
Extrinsic: autoimmune hemolytic (hot/cold), MAHA (TTP), HUS (shiga mediated or complement mediated),
Heart valve replacement,

Low retics:
Don’t forget it can be combo of IDA / AICD with e.g. B12

260
Q

What do you send for a hemolytic workup?

A

LDH, haptoglobin, bili

261
Q

What are the CRAB criteria for multiple myeloma

A

Hypercalcemia
Renal
Anemia
Bone pain

262
Q

What causes a normocytic anemia with low retics

A

Myelodysplastic syndrome, malignancy, aplastic anemia, infiltration (bone marrow)

263
Q

What is the appropriate ABx for this organism which was found in urethral discharge from a male

A

Azithromycin or doxycycline plus ceftriaxone

264
Q

How do you differentiate beta-blocker overdose from opioid overdose?

A

Beta-blocker = cardiogenic shock

Opioids tend to be pinpoint pupils, resp depression and resp acidosis

265
Q

In a hypertensive crisis, what guides choice of IV antihypertensives?

A

If hyperadrenergic eg. Pheo or MAOI Tyramine crisis, need to block alpha then beta receptors. Or use nitroprusside. Otherwise IV labetalol is a good choice and works in pregnancy

266
Q

What is the progression of silicosis?

A

Either acute (sudden onset respiratory failure, bilateral ground glass opacification, right heart strain or RVF) or chronic, which can be further categorized into simple or massive fibrosis

Clerkship (CC3) (12 decks)

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